The American Academy of Pediatrics recommends annual TB skin tests for all HIV-infected children; it is also recommended for children who reside with HIV-infected adults. TB testing information is required for the child’s participation. A TB skin test result must be documented within the past 12 months. This is an absolute requirement!

The American Academy of Pediatrics recommends annual TB skin tests for all HIV-infected children; it is also recommended for children who reside with HIV-infected adults. TB testing information is required for the child’s participation. A TB skin test result must be documented within the past 12 months. This is an absolute requirement!

Most recent TB Skin Test OR IGRA

MM

DD

YYYY

Result:

Chest x-ray (If test positive or hx of disease)

Chest x-ray (If test positive or hx of disease)

MM

DD

YYYY

Result:

If patient has history of TB infection, please indicate when treated

Date

Date

MM

DD

YYYY

SIGNATURE OF LICENSED MEDICAL PERSONNEL

SIGNATURE OF LICENSED MEDICAL PERSONNEL

First Name

Last Name

Title

Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Phone

(###)

###

####

Emergency Phone

Emergency Phone

(###)

###

####

Email

MEDICATIONS

Please list ALL medications (including over-the-counter and/or non-prescription drugs) taken routinely. Bring enough medication to last the entire week of camp. Keep all medications in their original packaging/ bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.